SVEIKATOS MOKSLAI / HEALTH SCIENCES IN EASTERN EUROPE ISSN 1392-6373 print / 2335-867X online 2020, 30 tomas, Nr.1, p. 48-55 48 VISUOMENĖS SVEIKATA / PUBLIC HEALTH DOI: https://doi.org/10.35988/sm-hs.2020.007

BEHAVIOR OF DIVERS AND RECOMMENDATIONS OF OTOLARYNGOLOGISTS CONCERNING DIVING: PILOT STUDY

Liubov Kornilenko1, Jelena Stanislavovienė1, Irina Arechvo2 1Faculty of Medicine, Vilnius University, 2Department of , Nose and Throat Diseases, Republican Vilnius University Hospital, Lithuania

Keywords: behavior of divers, diving contraindications, after the stapedoplasty, is different; 15% of the inter- ear . viewed doctors would recommend stopping diving for a definite period. Despite the recommendations Summary of doctors, 17.9% of divers continued to dive. The aim of the study is to estimate the possible risky Conclusions. This study shows that the behavior of behavior of Lithuanian divers and its relation to ear divers regarding the hearing health is often quite ri- damage as well as identify the opinions of Lithuanian sky. Lithuanian otolaryngologists are lacking con- otolaryngologists concerning contraindications and sensus of opinion on contraindications for diving. recommendations in the diving field. Material and methods. The authors compiled two Introduction separate questionnaires for Lithuanian divers and Diving is one of the activities that are the fastest growing otolaryngologists; in total, 84 questionnaires were in popularity. There are more than 10 million certified divers completed. Statistical tests were used to detect the worldwide [1], but the exact number of amateur divers in difference among answers of respondents who have Lithuania is unknown (the country has more than 20 di- distinct sociodemographic characteristics or different ving clubs) [2]. Due to significant air pressure changes, the diving/consulting experience. main health problems of divers are associated with and Results. It was revealed that 47.5% of divers experi- sinuses [1]. However, the residency of Lithuanian otolaryn- enced difficulties while equalizing the air pressure. gologists does not involve all aspects of diving medicine. More than half of the divers (57.9%) ignored this Because of the lack of doctor’s experience, difficulties can embarrassment and continued diving. was occur while giving advice to divers. It is generally accepted felt by 37.5% of the respondents during their diving that common ear and nose diseases, e.g. chronic media session. Half of the divers consulted a doctor because with perforation, chronic rhinosinusitis and nasal polyposis of the pain, others did not pay attention and procee- are contraindications for diving. However, modern treatment ded the diving. The third of the interviewed divers methods may increase the expectation for a full recovery and were diving though they had rhinitis. Most of them even to restore the ability to dive in many cases. Additionally, were diving without any medications. Only 13% of there is still no consensus of opinion regarding how long the those who experienced dizziness consulted a doctor. underwater activity should be prohibited after the usual oto- Absolute contraindications to dive are a tympanic laryngological procedures. The doctors should know about membrane perforation (90.9%), myringotomy tube the strong desire of divers to practice diving despite chronic inserted into a tympanic membrane (79.5%), and Eus- conditions. Previous studies have shown that divers continue tachian tube dysfunction (61.4%); these disorders are to dive despite suffering from contraindications [3,4]. most often reported by the interviewed otolaryngolo- The aim of this paper is to reveal the presence or absence gists. In this survey, 61.3% of the otolaryngologists of risky behavior of Lithuanian divers and opinions of otola- declared they would allow diving if there were no ryngologists about contraindications and recommendations symptoms of in the past 3–6 months. The concerning the diving activity. The researchers of this study opinion of otolaryngologists on diving in the case of believe that the results of it will help the communities of acute rhinitis, as well as on the returning to diving divers and otolaryngologists to understand each other better.

Žurnalo tinklalapis: http://sm-hs.eu Correspondence to: Jelena Stanislavovienė, e-mail: [email protected] 49

Materials and methods of the interviewed otolaryngologists reported that they had This study has been carried out from July to October in consulted divers in the past 12 months. The largest number 2015. Two separate questionnaires were created and sent of consulted divers per specialist within a year is 10 people to Lithuanian diving clubs as well as to otolaryngologists (Table 1). via e-mail. The questionnaire for divers included questions In the study, 40 questionnaires which had been comple- concerning demographic data (questions), diving history ted by the divers were used as well. The major part of these (), symptoms of ear disorders (), risk factors for the develo- respondents includes men who have approximately 6 years pment of ear diseases and diving habits that might affect the of diving experience (Table 2). Another characteristic of occurrence of otological complications (). Knowledge of the the interviewed divers is that sixty percent of them have a divers about their handling different underwater situations higher education. Most respondents (95%) have at least one () was evaluated as well as frequency of their consultations diving certificate. with medical specialists () and compliance with the recom- Study of otolaryngologists: contraindications for di- mendations of doctors (). ving and special ear conditions while diving. The con- In the questionnaire, otolaryngologists were asked to ditions noted by otolaryngologists as the absolute contra- provide their sociodemographic data (), information concer- indications for diving are presented in the Figure 1. The ning their work experience (), recommendations for divers, major part of the ENT specialists noted that open tympa- contraindications to diving () and their knowledge regarding nic membrane perforation and tube myringotomy are total the treatment of diving-related diseases (). contraindications to diving. Besides, about half of intervie- All eighty-four submitted questionnaires were completed wed specialists think that the records of and used in the analysis; the number of respondents is 40 dysfunction and open mastoidectomy in patient’s medical divers and 44 otolaryngologists. The data were analyzed history are contraindications for diving and only several using IBM SPSS Statistics software, version 21.0. ANOVA doctors would prohibit the diving if a patient had other ear was employed to compare the means of continuous variables. health conditions.. The choice of a particular questionnaire’s Chi-square and Fisher’s exact test were used to obtain signi- answer overall does not depend on the doctor’s job experi- ficant differences in proportions of categorical variables. In ence, a number of consulted divers per year, respondent’s this paper, the exact test results are presented only using the workplace. cases in which statistically significant differences between In regards to whether patients can continue diving after the groups can be observed (p < 0.05). a surgery (stapedoplasty), 38.6% of the interviewed oto- laryngologists (IOs) proposed the first consultation three Results months after the surgery, 34.1% suggested seeing the doctor This study includes 44 questionnaires completed by after one year, and 20.5% said that diving is contraindicated otolaryngologists whose average work experience is 20.01 after the stapedoplasty. The answer choice is related to the years (SD = 12.71). Тhe most of them (24 respondents) duration of work experience. The average work experience have worked both in outpatient departments and hospitals, of respondents who recommended diving one year after the others (17 interviewees) have worked entirely in outpa- the stapedoplasty is 28.07 years (SD = 12.2) vs. 14.82 ye- tients departments, and only 3 questioned otolaryngologists ars (SD = 10.66) of work experience of those doctors who mentioned a hospital as their sole workplace. Only 34.1% recommended diving 3 months after the surgery (F = 5.05, p < 0.05). Table 1. Characteristics of the interviewed ear, nose and throat The research reveals the opinion of otolaryngologists (ENT) specialists (otolaryngologists) concerning the workplace concerning the about diving when atrophic can and the number of divers they had consulted per year (n = 44). Table 2. Characteristics of the interviewed divers concerning the Characteristic Absolute % age, sex, diving depth and diving experience (n = 40). numbers Workplace Characteristic n = 40 Outpatient department 17 38.6 Average age 35.8 years (SD = 11.142) Hospital 3 6.8 Sex Outpatient department and hospital 24 54.5 Men n = 30 (75 %) Consulted divers per year Women n = 10 (25 %) None 29 65.9 Average diving depth 22.23 meters (SD = 8.122) From 1 to 10 15 34.1 Average diving experience 6.5 years (SD = 3.83) 50

Figure 1. Absolute contraindications for diving noted by the interviewed otolaryngologists. be seen otoscopically: there are 31.8% interviewed speci- 12.5% of doctors having 16-30 years of work experience alists who were convinced that diving causes ear traumas, and by 12.5% of those having from 31 to 45 years of work so their advice for patients is to stop diving; overall, 61.4% experience. of the interviewed doctors would allow diving under the Study of divers: difficulties equalizing the pressure, supervision of an otolaryngologist and a diving instructor. ear pain, and diving despite doctor’s recommendations. A few interviewees (6.8% of otolaryngologists) responded Less than a half of the interviewed divers (IDs), i.e. 47.5% that they would let a patient to dive, but before it they would of them, reported that they had difficulties equalizing the explain the risk of such activity. pressure under water, especially when they “caught a cold” Moreover, otolaryngologists were asked about specific or had an “ear infection”. Divers who had experienced this ear conditions caused by the changes in pressure, i.e. the difficulty behaved as follows: 15% (6) of the respondents differences between inner ear barotrauma (IEB) and inner immediately interrupted the diving, 10% (4) saw an ENT ear decompression sickness (IEDS). There are 43.2% res- specialist, and 27.5% (11) did not pay attention and conti- pondents who claim that IEB and IEDS are two different nued the diving. The latter group includes only the men. pathologies, 95.7% of interviewers say that the symptoms of Regarding the ear pain, 37.5% of divers experienced it these pathologies are similar, and 78.6% of medical specia- while they were diving. Only 8 respondents (20%) stopped lists state that the treatment of these pathologies is different. diving and visited a doctor after the occurrence of this symp- An inappropriate tactics for overcoming IEB (treatment in tom, whereas 10% of divers were searching for information pressure chamber) has been chosen by 18.2% of doctors. on the Internet how to solve this problem. Despite the pain, For IEDS management, 47.7% of respondents offer neces- 15% of the interviewees continued the diving without paying sary treatment using a hyperbaric oxygen chamber. The attention to the symptom. In the case of an acute ear pain otolaryngologist’s choice of hyperbaric oxygen therapy for or a feeling of fullness in the ear, 12.5% of the IDs did not treatment of IEDS depends on specialist’s duration of work know how to behave. Additionally, 42.5% of the respondents experience (χ 2= 4.02, df = 1, p < 0.05); the shorter it is, the reported that they would not recognize the symptoms of a more often doctors propose this therapy. In the group of IOs ruptured under the water. having from 1 to 15 years of work experience, 68.4% choose One part of respondents (15%) were recommended by the treatment using the chamber; the same therapy is chosen by doctors to stop diving for a period of time. However, 17.9% 51 of divers continued to dive despite the recommendations of to decide whether or not he/she can dive [8]. The authors of the doctors. this article believe that awareness of the diver’s motivation Vertigo and acute rhinitis. Contradictions between depends on the fact whether the patient will consult the doc- otolaryngologists and divers. Regarding vertigo, 37.5% tor in time or dive without medical supervision despite the of divers experienced it under the water during the diving contraindications. The minimal effect of forbiddance has and 12.5% of the IDs felt it when they were on the surface been previously mentioned [9]. of water. Only 5% of the interviewees complained of this The present study has revealed that some divers do not symptom to the ENT specialists. In the case of experien- recognize potentially dangerous situations happening under cing dizziness while being under the water, 63.6% of the the water and do not know how to behave in them, for exam- interviewed otolaryngologists recommend rising towards ple, in the case of acute ear pain (possible risk of the eardrum the surface of water as slowly as possible, 43.3% of the perforation). This finding helps to confirm the hypothesis ENT doctors advise their patients never return to diving after about the lack of awareness of divers in this situation. Accor- experiencing vertigo under the water, and 9.2% of medical ding to the literature, it is recommended to stop at the present specialists suggest exploring the cause of dizziness before depth under the water and perform an equalization maneuver; the next consultation. If there were no unexplained symptoms if the symptoms persist, discontinue diving and try to rise of vertigo in the past 3-6 months, 61.3% of the interviewed to the surface of the water using the decompression station. specialists would allow the divers to continue their favorite It is known that correct decisions should be made quickly activity. In the case of Meniere’s disease or other recurrent under the water. It is important not to blow too hard, which peripheral vestibulopathy, 52.3% of the interviewed otola- is usually done by divers when they panic while trying to ryngologists suggest discontinuing diving activity and 40.5% equalize the pressure [10]. More attention should be given of ENT doctors recommend to continue the diving under the to this topic in training or during the consultations with an supervision of a doctor and a diving instructor. otolaryngologist. Most of the otolaryngologists (65.9%) would recommend Only half of the IDs consulted the doctors in the event of stopping diving in a period of acute rhinitis while 31.8% of possible ear injuries. There is a possibility that the symptoms respondents would allow diving if their patient used antihis- signalizing ear injuries were disturbing the respondents only tamines, decongestants or topical corticosteroids. Further- temporarily or were not very intense. Half of the IDs experi- more, 12 interviewed divers (30%) periodically dive with a enced difficulties equalizing pressure between the runny nose and 20% of them have been doing it without any and nasopharynx and felt the ear pain. Difficulties while equ- medications. This behavior is related to the education level alizing the pressure may be associated with the Eustachian of respondents (χ2 = 5.030, df = 1, p < 0.05): more divers tube dysfunction (ETD) which is the risk factor of middle ear whose education is lower periodically have been diving with barotrauma [11]. The third of the IDs did not pay attention a runny nose without taking any medication. and continued potentially risky activities. The same situation was happening in the case of dizziness; only minority of the Discussion IDs consulted an otolaryngologist. Only a number of men SCUBA diving is a widely prevalent activity worldwide; chose the answer: “to ignore the symptoms and continue to however, the pre-selection system for assessing the health dive”. Certainly, behavior is not determined only by gender of divers is not perfect. To get a diving certificate, a person and attitude towards health depends on a person’s character should fill out a medical questionnaire [5]. However, accor- [12], but such results may confirm that overall, men tend to ding to this study results, there is a possibility that a person take risks more often and care less about their health than would not provide all the information about some impor- women [13]. It should be highlighted that 17.9% of divers tant medical conditions because of his strong motivation to claimed they would dive despite the recommendations of dive. It is suggested that objective methods should be used their doctors not to act in such a way. more often, even in the cases of amateur divers. There is a One third of the IDs are smokers. The habit of smoking list of relative and absolute contraindications, but how to has a relation with education; the higher the education is, consult the divers exactly and what advice should be given the less often (or more rarely) the questioned divers smoke. in each particular case does not seem completely clear [6]. Smoking is a risk factor for the development of ETD [3]. The Recommendations generally resemble to the personal advices survey reveals that the third of the divers continue to dive and opinions of the distinct doctors are often different [7]. despite having rhinitis and some of them were diving without Meanwhile, the Divers Alert Network (DAN) emphasizes any medication, more often the lower educated individuals. that the diver must always consult his or her doctor in order The named facts show that behavior of these divers is risky 52 and they tend to act dangerously despite the information the vestibule of the patient [16]. On the other hand, there are provided during courses. Recommendations from the IOs also contradicting opinions of various researchers provided differ regarding the diving in the cases of acute rhinitis. In in the medical literature [6,20]. Some authors recommend general, the top recommendation is to limit diving during the assessing the patient’s condition with the help of impedan- periods of acute rhinitis. As regards the acute rhinitis, in the cemetry before his/her returning to diving; if there is no sign medical literature there have been mentioned that the use of of a disturbance, the existing risk should be explained and topical or systemic decongestants can help (if an individual then the patient should be allowed to dive [19,21]. Some IO is continuing to dive, it is better to use these decongestants propose to hold the consultation with the patient one year than to dive without them) [14]. after the stapedoplasty and others (almost the same number Most commonly recommended absolute contraindications of respondents) suggest to arrange the consultation three to dive by otolaryngologists are an open tympanic membrane months after the surgery. The authors of this article did not perforation, tube myringotomy, and ETD. According to the separate the otosurgeons and otoneurologists into different literature, the eardrum perforation is attributed to high-risk groups of specialists; their opinions would probably be the conditions and to absolute contraindications for diving be- most important. According to the conclusions drawn by cause of caloric vestibular irritation and the chance of ge- House and Toh [22], the risk of inner ear barotrauma after tting an infection [15,16]. The authors of medical writings stapes surgery has not been increased in SCUBA divers; recommend waiting for approximately 2 months after the they reported that the activity can be relatively safe after eardrum perforation will have been healed, then the otola- the accompanied by the adequate Eustachian ryngologist should ensure that it was healed well enough and tube function. there are no symptoms of ETD [17]. Today, there are special Myringoplasty is one of the most common otologic pro- ear protectors for divers that allow the divers to keep their cedures; therefore, questions concerning diving after this type ears dry after the occurrence of eardrum perforation [18]. of surgery are important and practical. One fifth of the IOs The medical literature suggests that acute ETD, only in claim that the record of myringoplasty in patient’s medical the cases when it is absolutely impossible to carry out the history is an absolute contraindication to diving. An eardrum equalization maneuver, is an absolute contraindication to becomes less stable after the surgery than before; therefore, diving [16]. the risk of perforation remains [15], especially when fascia Half of the IOs stated that the patients should never return of the temporal muscle or tragus perichondrium is used. to diving after the radical ear surgery or having a record of An otolaryngologist should evaluate aeration of the middle open mastoidectomy in their past medical history. Some ear and stability of the reconstructed tympanic membrane authors claim that a patient should not dive after the radical after the each ear surgery. Cartilage can be surgery because the flow of cold water inside the cavity can an alternative for divers as it provides more stability for the provoke vertigo [19]. Other authors emphasize that effects on eardrum by becoming more resistant in a pressure-changing the vestibular system may be different and they depend on environment. the size of operations and the access. To determine whether a More than half of the IOs would let a patient continue patient is allowed to dive, a provocative test (posturography diving under a supervision of an otolaryngologist and a di- with cold water which is poured into the affected ear while ving instructor. In the medical literature, it has been men- changing the patient’s body position and monitoring nysta- tioned that patients who previously had the atrophic ear- gmus at the same time) must be carried out [15,16]. In recent drum without perforation that remained stable during the years, an increasing number of surgeons have been choosing equalization maneuver could be allowed to dive. However, to perform a mastoidectomy with cavity obliteration because the patient should be given explanation about the risk of patients can return to their normal water activities after a perforation [15]. Surgery might be proposed (before ulti- surgery and drawbacks of open techniques can be avoided. mately forbidding the diving) if increased pressure causes The current attitude of IOs towards diving after the sta- eardrum instability [6,15]. Diving in a swimming pool under pedoplasty can be defined according to the following in- the supervision of a diving instructor could be proposed to formation: one third of respondents claim that they would determine if vertigo occurs under the water and the eardrum forbid the diving after this surgery. The Professional Asso- surgery is needed [19]. ciation of Diving Instructors (PADI) attributes a record of Opinions of the IOs are different on the compatibility stapedoplasty in patient’s medical history to the possible of Meniere’s disease or other known peripheral vestibulo- conditions of severe risk. It is known that after the stapes pathy with diving activity. One group of specialists claim that surgery, there remains a danger of prosthesis dislocation into such diseases are absolute contraindications to dive; another 53 group would allow diving along with otolaryngologist and difficult to separate IEB from IEDS – it requires a diving diving instructor consultations. DAN proposes that only often risk assessment, thorough examination of patient’s medical recurring episodes should be an absolute contraindication history, clinical evaluation, pure tone audiometry, fistula test, to dive [23]. If there are no repeated episodes, the authors and [26]. Revision surgery of the recommend the provocation tests and trying to dive in a middle ear is indicated only in the cases when the patient’s swimming pool with a diving instructor [19]. condition is severe or if vestibular and auditory symptoms In the cases of underwater vertigo, more than half of the show no improvement within 10 days after the event [26]. IOs suggest moving slowly to the surface of the water and Hyperbaric treatment is not needed for IEB healing; the more a little less of them would prohibit diving. It is known that so, it can cause worsening of the condition [27]. Treatment underwater vertigo may be a life-threatening because of an for IEDS demands recovery of fluid balance, the supply of increased risk of drowning. Therefore, if it happens often, oxygen through a mask and immediate transportation of some authors recommend stop to dive [15]. Divers who expe- the patient to a place where a hyperbaric oxygen therapy rienced alternobaric vertigo (a common finding in divers chamber is located [1,28]. [24]) had not been consulted about dangerous situations, so One of the limitations of the study was that the response the risk is considered being low. Doctors should differentiate rate of otolaryngologists and divers was suboptimal and the the causes of vertigo before allowing their patients to dive. authors need further researches to provide more scientifically More sophisticated vestibular tests (videonystagmography) based conclusions. might be needed [19,24]. The research revealed on this paper has showed that majority of the respondents would allow Conclusions diving after a 3-6 month asymptomatic period (more than Our study has showed that the habits and behavior of half of them would choose a 6-month period). According to some divers are quite risky. Not all divers know about the the literature, absolute contraindications to dive include an ear injuries occurring under the water and how to address acute vestibular impairment after vertigo up to 6 months or potentially life-threatening situations. Attention should be signs of nystagmus noticed during a provocation test [15]. paid to these aspects of diving in diving courses and all pos- The results of this study has showed that there is no consen- sible educational facilities should be used. The interviewed sus among otolaryngologists; therefore, further prospective doctors understand the motivation of divers to be involved studies are needed. in their favorite activity, besides, the IOs a wish to satisfy The study carried out by the authors of this article shows their patients there are no absolute restrictions on the part of that the interviewed otolaryngologists rarely consulted di- doctors. However, Lithuanian otolaryngologists are lacking vers. This situation has probably emerged because the ma- exact consensus on contraindications for diving; ear injuries jority of otologic injuries were minor and divers recove- should be a more discussed topic to seek for a common red spontaneously or with the help of online specialists or solution. There is also a need of knowledge about specific general practitioners. Another possible explanation is that otologic conditions related to diving. the interviewed divers were consulted by foreign medical specialists, as the most popular places to dive are generally References outside of Lithuania. The study shows a lack of specific 1. Klingmann C, Praetorius M, Baumann I, Plinkert P. Barotrauma knowledge of Lithuanian otolaryngologists concerning the and decompression illness of the inner ear: 46 cases during diving. This lack of knowledge is especially noticeable when treatment and follow-up. Otol Neurotol 2007;28:447-454. distinguishing the differences between IEB and IEDS. 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Health aspects of diving in ENT grįžo 84 anketos. medicine. Part II: diving fitness. HNO 2004;52:845-847. Rezultatai. Iš viso 47,5 % apklaustų narų jautė sunkumą, ban- https://doi.org/10.1007/s00106-004-1105-1 dydami išlyginti slėgį po vandeniu. Daugiau nei pusė narų (57,9 %) 55 nekreipė į šį pojūtį dėmesio ir nardė toliau. Ausies skausmą nar- rinito laikotarpiu ir įvykus stapedoplastikai, otorinolaringologų dydami jautė 37,5 % apklaustų narų. Dėl šios priežasties pusė iš nuomonės išsiskyrė. Iš viso 15 % šių gydytojų rekomendavo ne- jų kreipėsi į specialistus, kita dalis nekreipė į skausmą dėmesio nardyti tam tikrą laikotarpį. Nepaisant specialistų rekomendacijų, ir tęsė nardymą. Trečdalis apklaustųjų nardė, sirgdami sloga. Di- 17,9 % apklaustų narų tęsė nardymą. džioji dalis jų užsiėmė nardymu, prieš tai neišgėrę jokių vaistų. Išvados. Tyrimas atskleidė gana rizikingą su ausų sveikatos bū- Tik 13 % nardytojų, patyrusių galvos svaigimą, kreipėsi į specia- kle susijusį nardytojų elgesį. Lietuvos otorinolaringologų nuomo- listus. Dažniausiai ototrinolaringologų nurodomos absoliučiosios nės dėl nardymo kontraindikacijų išsiskyrė – trūksta bendro suta- nardymo kontraindikacijos yra būgnelio perforacija (90,9 %), bū- rimo, konsultuojant narus. gnelyje esantis timpanostominis vamzdelis (79,5 %) ir ausies tri- Adresas susirašinėti: [email protected] mito disfunkcija (61,4 %). Apskritai 61,3 % apklaustų otorinola- ringologų leistų savo pacientui nardyti, kai po galvos svaigimo yra Gauta 2019-11-15 praėjęs 3–6 mėn. besimptominis laikotarpis. Dėl nardymo ūmaus